Women's involvement in decision-making and receiving husbands’ support for their reproductive healthcare: a cross-sectional study in Lalitpur, Nepal

Abstract Background Sociocultural factors remain an important determinant for women's involvement with decision making and getting husbands’ support for their reproductive healthcare. Therefore this study was conducted to examine sociodemographic factors associated with women's involvement in decision making and getting husbands’ support for their reproductive healthcare. Methods An institutional-based cross-sectional study was conducted in Lalitpur, Nepal. A total of 600 respondents were selected from 15 immunization clinics. Participants were women ≥18 y of age who came to the child's immunization clinic. The association between sociodemographic variables and women's involvement in decision making and getting husbands’ support for their reproductive healthcare was analysed through multivariate logistic regression models. Results While women's involvement in decision making was greater for childcare, it was less in the area related to financial matters. In contrast, husbands supported more in the area related to finances than for childcare and accompanying to health facilities. The significant determinants for women's involvement in decision making and getting husbands’ support were the woman's caste, education level, employment status, household income, age group and number of children. Madhesi/Muslim/other women were less likely (adjusted odds ratio [AOR] 0.31 [95% confidence interval {CI} 0.12 to 0.73]) to decide the number of babies and birth spacing. These women were also less likely (AOR 0.18 [95% CI 0.02 to 0.86]) to be accompanied by their husbands to the family planning (FP) clinic. Janajati, Dalit and Madhesi/Muslim/other women were less likely to receive their husbands’ support for birth preparedness. Women who were <20 y of age and had a single child were less likely to get involved in decision making and getting their husbands’ support for FP services. Conclusions The findings call for reproductive health programs that encourage women's involvement in decision making and receiving husbands’ support in women's reproductive healthcare. When designing such a program in the FP area, the woman's caste, age and parity should be given special consideration. Also, caste should be considered when designing such a program related to birth preparedness.


Introduction
Reproductive healthcare access and utilization are affected by many sociocultural factors, including women's involvement in decision making and getting husbands' support for their reproductive healthcare. 1,2 Women's involvement in decision making was found to reduce the unmet need for family planning (FP), 3 improve antenatal care (ANC) visits, 2 and improve birth preparedness. 4 Despite the significance, globally one-quarter of women cannot decide on their reproductive healthcare. 5 This is because husbands remain the sole decision maker for their wives' reproductive healthcare access and utilization. 6 As a result, many women are hindered from accessing and utilizing reproductive healthcare services. 6 Also, women do not hold financial authority, are shy to be exposed to outsiders and are not educated enough to understand the instructions at the health facility. 6 They have to rely on their husbands' support to access and utilize reproductive healthcare services. 6 A meta-analysis showed that the husbands' involvement improved overall utilization of maternal health services. 1 Also, the husbands' support in household chores during the postnatal period improved maternal health outcomes. 7 Therefore women's involvement in decision making and getting husbands' support are essential to increase the utilization of reproductive health services and improve maternal health outcomes. 1,8 Knowing the situation of women's involvement as decision makers and husbands' involvement as supportive partners for women's reproductive healthcare are pivotal for achieving universal access to reproductive health. 1,9 Past studies have assessed women's and their husbands' involvement in reproductive healthcare. However, most of these studies have focused on either contraception, ANC or institutional delivery. 1,10 Only a few studies have assessed all these components together in a single study and included childcare components such as immunization and breastfeeding. 11,12 Further, despite having a significant impact on maternal health outcomes, 7 little evidence exists on the situation of husbands' support with domestic chores during pregnancy and postnatal periods. Furthermore, variations were found across husbands' involvement in different components of reproductive health. For instance, husbands supported more in the financial area than accompanying to health facilities. 11 As variations exist across different components of reproductive healthcare, it is crucial to analyse the components together in a single study to visualize the existing situation better.
In many countries, including Nepal, patriarchal traditions exist in many societies and sociocultural factors are important determinants for different life courses. 13,14 The existing gender norms and sociocultural factors influence women's involvement in decision making and receiving husbands' support for their reproductive healthcare. 14 Knowing the sociodemographic determinants for women's involvement with decision making and getting husbands' support will help in designing a focused and targeted program, particularly in the context of Nepal. Despite the importance, little is known about the influence of this sociodemographic characteristic on women's involvement in decision making and receiving husbands' support over different components of reproductive health. Further, very limited evidence exists for sociodemographic determinants of husbands' involvement in childcare and domestic chores. Considering all these research gaps and needs, this study was conducted to identify sociodemographic factors associated with women's involvement in decision making and getting husbands' support for their reproductive healthcare (FP, ANC, birth preparedness and childcare).

Study design and setting
An institutional-based, cross-sectional study was conducted in the Lalitpur district of Nepal. The population of Lalitpur district is 468 132. 15 It comprises one metropolitan city, two urban municipalities and three rural municipalities. 16 Despite being close to the country's capital, the reproductive health indicators of Lalitpur district are not satisfactory. 17 As the majority of the children in Nepal are taken to the immunization clinic by their mother, the immunization clinic was considered a study setting for this study. 12,18 There are 42 government-run immunization clinics in Lalitpur district. 16 These are static clinics located within the government-run health facility and are run by the health facility staffs. Some of these clinics also run outreach service in the community. 19 However, for this study only the immunization clinic located at the health facility was included. These clinics run monthly, bimonthly, trimonthly or weekly, depending upon the client flow.

Study participants and sampling
All women >18 y of age who took their child to the immunization clinic were included in the study. The national immunization program of Nepal provides routine vaccination to children from 0 to 15 months of age. Samples were selected in two stages. In the first stage, 15 of 42 government-run immunization clinics were selected through a simple random sampling method. Three immunization clinics were selected from one metropolitan city, three from each of the two urban municipalities and two from each of the two rural municipalities, making a total 15. The number of health facilities from each municipality was purposively decided for better representation. In the second stage, 40 eligible women were consecutively selected from each immunization clinic. Because immunization clinics in Nepal have a walk-in system, random sampling was not possible in the second stage. The sample size was determined using the following assumption: proportion of husbands' involvement was 39.3%, 12 5% margin of error, 10% non-response rate and design effect of 1.5. 20 The final sample size was calculated to be 597.

Sociodemographic variables
The sociodemographic variables used in this study were the women's age, education level, employment status, aggregated annual household income in Nepali rupees (NPR), caste, years of marriage and the number of children. [11][12][13] The categorization of the sociodemographic variables was adopted using the Nepal Demographic Health Survey (NDHS) 2016. 21 The nominal median household income of 127 281 NPR from the Nepal Living Standard Survey 2010/11 was considered the cut-off point for the aggregated annual household income. 22 The median value was considered a cut-off point for the duration of the marriage and the number of children.

Outcome variables
The main outcome variables were women's involvement in decision making (yes/no) and receiving husbands' support for their reproductive healthcare (yes/no).

Women's involvement in decision making
A woman was considered to be involved in decision making for her reproductive healthcare if decision making was done alone or jointly with her husband. The women's involvement in decision making was assessed for contraceptive method, choice of International Health FP clinic, the number of babies and birth spacing, having an antenatal check-up, choice of the birthing centre, choice of transportation to the birthing centre, having exclusive breastfeeding and immunization of the child.
Receiving husbands' support for women's reproductive healthcare A woman was considered to receive her husband's support if she responded 'yes' to the questions related to it. Receiving husbands' support was assessed for accompanying to the FP clinic, accompanying to the antenatal clinic, helping with domestic chores during pregnancy, saving money for childbirth expenses, arranging the birthing centre, arranging transportation to the birthing centre, assisting with breastfeeding, helping with domestic chores during the postnatal period and accompanying to the child immunization clinic. Women whose husbands were not present (outmigrants) during the period of pregnancy, childbirth and child care were excluded from the analysis. However, exclusion was not applied for saving money, as it was possible without physical presence.

Validity and reliability
The questionnaire items were adapted from survey tools and indicators for maternal and newborn health developed by Jhpiego, an affiliate of Johns Hopkins University, 23 NDHS 21 and relevant prior studies. [11][12][13] The questionnaire consisted of sociodemographic characteristics of the women, women's involvement in decision making and receiving husbands' support for their reproductive healthcare. As the questionnaires were not available in the Nepali language, they were checked for cultural adaptation through translation and back-translation to the Nepali language and pretesting of the questionnaire. The content validity was ensured through two expert opinions, two focus group discussions (FGDs) among women and pretest of the questionnaires. The pretest of the questionnaire was done among 60 respondents in the Chhetrapati Family Welfare Clinic, Kathmandu. The value of Cronbach's α was 0.84 for total decision-making questionnaires (eight items) and 0.91 for receiving husbands' support (nine items). Necessary modifications were made from the result of the pretest and FGDs.

Data collection
The tool for data collection was a structured questionnaire. The data collection was done from November 2018 to February 2019. Three research assistants were hired for data collection. The research assistants were trained and supervised for data collection.

Data analysis
Descriptive statistics were used to summarize the sociodemographic characteristics of women, women's involvement in decision making and receiving husbands' support for their reproductive healthcare. Multicollinearity was checked through the variance inflation factor. None of the sociodemographic variables were found to be multicollinear. Multivariate logistic regression analysis was used to identify the association of sociodemographic variables with women's involvement in decision making and receiving husbands' support for their reproductive healthcare. Eight different models for decision making and nine different models for receiving husbands' support were run. The models included the variables with theoretical or rational associations from prior studies. 11,12 The significance level was set at 0.05 and analysis was conducted using R Studio version 1.2.5001 (R Studio, Boston, MA, USA). Table 1 shows the background characteristics of the women. A total of 600 women participated in the survey. A total of 514 (85.7%) women were >20 y of age. There was an equal percentage distribution of women for different categories of education level. Of 600 women, 25.3% of the women had no education and 26.1% had an education level above a school leaving certificate (SLC). More than two-thirds of the women (79.0%) worked as non-wage earners and 85.0% had an aggregated annual income >127 281 NPR. About half of the women belonged to the  Janajati caste (49.0%). More than half of the women were married for <2 y (60.3%) and had a single child (53.0%). Receiving husbands' support for women's reproductive healthcare Table 3 presents the husbands' support for women's reproductive healthcare. Among 600 women, 337 had used or were using a female modern contraceptive method. Among the 337 women, 69.4% were never accompanied by their husbands to the FP clinic. Of 600 women, 56.0% were accompanied by their husbands to the ANC clinic and 59.0% were helped with domestic chores during pregnancy. The majority of the women (84.5%) were supported in saving money for childbirth expenses by their husbands. About two-thirds of the women's husbands helped arrange the birthing centre (65.3%) and transportation to the birthing centre (64.6%). About half of the women did not receive their husbands' support for breastfeeding (48.8%) and were not accompanied to the immunization clinic (57.5%). More than half (58.1%) of the women were supported by their husbands for domestic chores during the postnatal period. Only 8.0% of the women said their husbands were not present during the pregnancy and childcare period. Table 4 shows the association of sociodemographic factors with women's involvement in decision making for their reproductive healthcare by multivariate logistic regression analysis. There are a total of eight models for each question of decision making.  Table 5 presents the association of sociodemographic factors with receiving their husbands' support for women's reproductive healthcare by multivariate logistic regression analysis. There are nine models for each question of receiving their husbands' support. Women <20 y of age were less likely (AOR 0.38 [95% CI 1.14 to 0.95]) to be accompanied by their husband for the FP clinic than women >20 y of age. Women with an aggregated annual household income >127 281 NPR were more likely to be accompanied to the FP clinic (AOR 2.31 [95% CI 1.43 to 4.59]) and have money saved (AOR 3.50 [95% CI 1.95 to 6.23]) by their husbands than women with an aggregated annual household income <127 281 NPR. Women with an education level above an SLC were more likely to receive support from their husbands in all nine components than women with no education.

Sociodemographic factors associated with receiving husbands' support for women's reproductive healthcare
Women who belonged to the Dalit (AOR 0.31 [95% CI 0.10 to 0.84]) and Madhesi/Muslim/other (AOR 0.18 [95% CI 0.02 to 0.86]) were less likely to be accompanied by their husbands to the FP clinic. Women who belonged to the Janajati, Dalit and Madhesi/Muslim/other were less likely to receive their husbands' support in saving money for the birth expenses, arranging the birthing centre and arranging transportation to the birthing centre than those of the Brahmin and Chettri castes. Women married for <2 y were more likely (AOR 2.18 [95% CI 1.19 to 4.08]) to receive their husbands' support for arranging transportation to the birthing centre than women married >2 y. Women having a single child were less likely (AOR 0.36 [95% CI 0.14 to 0.91]) to be accompanied by their husbands to the FP clinic than women with more than one child.

Discussion
Women's involvement in decision making was more in the area related to childcare than finances. In contrast, husbands supported more in the area pertaining to finances than for childcare and accompanying to health facilities.
This study showed that women were less involved in decision making that included financial matters, such as having an ANC check-up, birthing centre choice and choice of transportation to the birthing centre. In contrast, their involvement was higher for childcare, such as deciding on immunization and breastfeeding. The possible explanation could be due to the existing gender norms of society. The financial burden of healthcare is shouldered by men, but childcare is exclusively considered a women's responsibility. 14 Past studies found a significant association of women involved in decision making and increased maternal health service utilization. 3,8,24 Therefore, women's involvement in decision making for their reproductive healthcare should be encouraged, focusing on components related to financial matters, such as the choice of transportation and birthing centre.
Less support was received from husbands for accompanying to the FP clinic, ANC clinic and child's immunization clinic. Similar findings were observed in past studies. 11,25 Some of the possible barriers could be male-unfriendly reproductive health facilities, the negative attitude of healthcare providers and the perception that it is exclusively a woman's activity. 26,27 This study also found that more women received support from their husbands for reproductive healthcare related to financial matters than childcare. This could be because of the existing gender norms of society, where childcare is considered a woman's responsibility. 14 Also, the role of mother-in-law as a primary caretaker during the postnatal period could have made it unnecessary for husbands to be involved in childcare. 14 However, a past study showed that women want their husbands to get involved in childcare. 28 Also, a prior systematic review found a significant association between husbands' support and women's reproductive health service utilization. 1 Therefore, programs that encourage husbands to accompany their wives to the reproductive health and immunization clinics should be considered, as well as programs that encourage their participation in childcare activities.
This study showed that Brahmin and Chettri women were more likely to get involved in decision making regarding the number of children and birth spacing and were accompanied by their husbands to FP compared with the other castes. The 2016 NDHS shows no significant differences among the castes for the unmet need for FP. 21 However, another study from Nepal shows a high unmet need among Muslims. 29 The Dalit, Janajati and Madhesi/Muslims/other are considered lower castes than the Brahmin and Chettri by traditional Nepali society. 30 These caste groups have lower literacy status and higher poverty levels than the Brahmin and Chettri. 30 In addition to lower literacy and income level, not being involved in decision making and getting husbands' support for FP service uptake may further decrease their rate of FP service utilization. Thus further consideration should be given to the caste when designing programs related to increasing women's involvement in decision making and getting husbands' support for FP service. It was also evidenced from this study that women belonging to the Dalit, Janajati and Madhesi/Muslim/other were less likely to get involved in decision making in choosing the birthing centre. Also, these groups of women were less likely to get support from husbands for birth preparedness (saving money, arranging the birthing centre, arranging transportation to the birthing centre). The national data of Nepal reports lower reproductive health service utilization among these groups of women compared with the Brahmin and Chettri. 21 One important strategy to increase reproductive health services utilization and prevent obstetric emergencies is to have a birth preparedness plan. 11 Not being involved in decision making and getting husbands' support for birth preparedness may further decrease their reproductive health service utilization rate and increase obstetric emergencies. Therefore, when designing a program to improve husbands' involvement in women's reproductive healthcare, special consideration should be given to the caste.
Women <20 y of age and who had a single child were less likely to be accompanied by their husband to the FP clinic. Similarly, women who had a single child were less likely to get involved in decision making in the choice of contraception and the FP clinic. The 2016 NDHS data reports a higher unmet need among women who were young and had fewer children. 21 A prior study found a lack of women's involvement in decision making and husbands' involvement as a key determinant for high unmet need for FP. 31 Therefore, when designing an FP program to encourage women's decision making and husbands' involvement in FP service utilization, special consideration should be given to young women.
This study also found that women with a higher annual household income were more likely to get involved in decision making for ANC check-ups. These women were also more likely to receive their husbands' support for accompanying to the FP clinic and saving money. The decision to have an ANC checkup and transportation certainly involves financial matters, and having a higher income would undoubtedly facilitate these decisions. 32 Further, receiving husbands' support to save money and being accompanied to an FP clinic is possible when income is higher. 12 Therefore, further consideration should be given to women with lower household incomes when designing such a program.
Women who were wage earners were more likely to get involved in decision making for the choice of the birthing centre and transportation to the birthing centre. A similar result was found in past studies in Nepal and other countries. 13,32 Working women have greater financial independence and do not depend upon their husbands for decision making. 32 Having financial independence enables women to choose the birthing centre and transportation to it. 13 Also, in this study, no significant association was found for being a wage earner and greater support from husbands. However, a past study found it to be significant. 32 Studies that explore the underlying reason are recommended.
Women who had higher education were more likely to be involved in decision making and receiving husbands' support for their reproductive healthcare. Similar findings were present in past studies. 12,32 Education empowers women to make decisions about their reproductive health and receive support from their husbands. 32

Limitations
This study might have selection bias. Women coming to child immunization clinics are more likely to utilize reproductive healthcare services, thus this study might not have captured the women who did not utilize the child immunization services, were sick or whose family members took the responsibility of bringing the child to the immunization clinic. However, since the immunization coverage is high and the majority of the children in Nepal are brought to immunization clinics by their mothers, the selection bias is likely to be limited. 18,21 There may also be social desirability bias while reporting the answers for decision making and receiving husbands' support. We tried to overcome this by taking data from women alone in a secure place. Lastly, whether women want their husband to be involved as a decision maker and supporter was not assessed in this study. Also, the underlying reason behind decreased involvement in decision making and receiving their husbands' support was not explored.

Conclusions
While women's involvement in decision making was higher for childcare, it was less in the areas related to financial matters. More husbands' support was received in the areas related to finances than for childcare and accompanying to health facilities. These findings call for programs that encourage women's involvement in decision making and husbands' support for women's reproductive healthcare. Also, significant determinants for women's involvement in decision making and receiving husbands' support were caste, education level, employment status, household income, age group and the number of children. These sociodemographic characteristics should be considered when designing programs to strengthen women's decision making involvement and getting husbands' support for their reproductive healthcare. When designing such a program in the FP area, emphasis should be given to caste, age of the women and parity. Also, caste should be particularly considered when designing programs related to birth preparedness.
Authors' contributions: AP and SDP were responsible for the study conception and design, data analysis and drafting and editing the manuscript. AP was responsible for training and supervising research assistants and checking the completeness of collected data. Both authors read and approved the final manuscript.
voluntary. Research objectives were explained to the women before each interview and written informed consent was obtained from all participants. In order to maintain privacy, a separate room was used for the interview.

Data availability:
The data that support the findings of this study are available from the corresponding author upon reasonable request.